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APPLICATIONFORPERMIT <br /> r ti; <br /> SAN JOAQU,IN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEARIFROM'DATE ISSUED'° <br /> y iComplete in'Triplicate? _� 1 <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work herein described. This application is <br /> m <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pup and the R41es and Regulations of the San Joaquin <br /> Local Health Districtt� <br /> . ' I f' } <br /> •� # w <br /> Job Address t City Lot Size' PM `r <br /> t•ti r} a <br /> Owner's Name L' 4ffl"S Address Phone <br /> Contractor Address 4ti License No. Phone XT-ni2114 <br /> 1 <br /> TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. " PROP. LINE <br /> FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50'1 j <br /> Depth Filler Material (Below 50') o~ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> available within 200 feet./ <br /> Installation will serve: Residence Commercial_X_ Other l" <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dispo al ¢ � <br /> ,��� <br /> Distance to nearest: Well�L.� Foundation Property Line <br /> T <br /> LEACHING LINE j] No. & Length of lines Total length/size " <br /> f <br /> FILTER BED ❑ Distance to nearest: Well ift <br /> a Foundation Property Line _ <br /> SEEPAGE PITS ❑ Depth { Size Number <br /> SUMPS ❑ Distance to"nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant muall f r all re u red inspections. Complete drawing on reverse side. c� ¢/ i <br /> i Signed _ S Title: 7 Date: /0_2x" 96 <br /> FOR DEPARTMENT USE ONLY <br /> date 0— Area b <br /> A���pjjcQQa��tppio{{n��Accepted by �L Q� <br />'i <br /> Prt�orr@r Tln,pebtionby Date in his�ecti+�n�by Date 7- <br />€ Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit!Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE. AMOUNT DUE AMOUNT REMITTED C K# RECEIVED BY DATE'., PERMIT"N30. <br /> INFO <br /> `Si `�10 l <br /> +,�Ndy1,3-24„(!§EV. ' � � r--� <br /> _7C) 0,:n � �,p <br /> EH W26 <br />